Unmet Needs and Key Takeaways When Treating mCSPC

Dan Petrylak, MD: There are several other studies that are now being done to move some other treatments earlier in the course of the disease for those patients who have DNA-repair mutations. There are trials that are looking at PARP [poly adenosine diphosphate-ribose polymerase] inhibitors early on to determine whether that's going to give patients a greater advantage in survival. PSMA [prostate specific membrane antigen] targeted therapies, such as the tissue and PSMA trials, are also being planned in the early state. We do need new agents to help improve overall survival, if we want to use that word, curative, but potentially delay progression and improve survival in our patients. What I think we really need are good markers to determine who should receive early chemotherapy versus those patients who should receive chemotherapy plus next-generation hormone therapy; I think biological markers are key. Moving new drugs up earlier into the castration-sensitive state is also important.

I think there's several things that we can do to improve the quality of our patient's lives and to counsel the families in the situation. Even though right now, PARP inhibition is not indicated for a patient who's hormone-sensitive, all of my patients who have metastatic disease have next-generation sequencing. We examine whether they have any germline mutations that may be significant, particularly BRCA1, BRCA2. That has implications when the patient becomes castration-resistant. Right now, there's no indication for using these drugs in the sensitive state, but also in terms of the family and whether the family needs to undergo genetic counseling and genetic screening. Patients also like to have a roadmap. They like to know what's in the future for them, what's going to happen to them if their disease begins to progress. I think it's important to emphasize right at the beginning that this disease is controllable and not curable. Controllable is really the word to emphasize: how can we help our patients live better? Number 1 of importance is helping these patients to maintain muscle mass and to control their weight. I recommend that the patients exercise, particularly also including weightlifting to maintain their muscle mass. I also tell them that they should try to limit their calories and follow a low-fat diet; just general healthy things that one would use for patients who may, for example, have heart disease. Bone health is also important. All of my patients undergo treatment with calcium and vitamin D. If they have low volume disease, they'll get a DEXA scan to see if they have an adequate bone density. If not, then the appropriate agents are missed for their DEXA scans. In summary, I think quality of life and quantitative life are important. It's important that our patients maintain as healthy and active a lifestyle as they possibly can.

This transcript has been edited for clarity.

Case 1: An 80-Year-Old Man With Metastatic Castration-Sensitive Prostate Cancer

Initial presentation

• An 80-year-old man presents with nocturia and decreased appetite
• He has mild pain in his hip and lower back

Patient History, Lifestyle and Clinical workup

• No family history of prostate cancer
• Patient is a widower without transportation for regular medical visits
• He is physically frail but his cognitive function is good
• TRUS and biopsy revealed adenocarcinoma of the prostate gland, Gleason grade group 3 [3+4] with disease in 8/12 cores.
• PSA 500 ng/mL; Hb 9.4 g/dL; ANC 1.5
• Bone and CT scans showed 1 metastatic lesion in the pelvis

Diagnosis

• Patient is diagnosed with de novo metastatic castration-sensitive prostate cancer
• Germline genetic testing is negative

Treatment

• Patient is started on ADT at diagnosis with initial decrease in PSA
• He expresses interest in receiving more intensive treatment to control his PSA
  • However, he does not want to receive chemotherapy since he has heard about the risk of side effects
  • He is looking for a treatment option that will allow him to have a good quality of life
• Due to his frailty, inability to make frequent medical visits and request not to receive chemotherapy, the patient is treated with ADT + apalutamide
• At his 1-year follow-up, the patient’s PSA remains undetectable, and he continues to report a good quality of life

Case 2: A 62-Year-Old Man With Metastatic Castration-Sensitive Prostate Cancer

Initial Presentation:

• A 62-year-old man presents to the emergency room with progressive fatigue, low back pain, decreased appetite, weight loss, abnormal rectal exam and urinary retention

Patient History, Lifestyle and Clinical workup

• Past medical history is unremarkable
• No family history of prostate cancer
• Biopsy revealed adenocarcinoma of the prostate gland, Gleason grade [4+4] with disease in 8/12 cores.
• PSA 200 ng/mL; Hb 9.5 g/dL; ANC 1.7
• Bone and CT scans showed 2 metastatic lesions in the pelvis
• ECOG PS is 1

Diagnosis

• Patient is diagnosed with de novo metastatic castration-sensitive prostate cancer
• Germline genetic testing is negative

Treatment

• Patient is started on ADT plus abiraterone at diagnosis with initial decrease in PSA

EP: 1.Case 1: An 80-Year-Old Man With mCSPC

EP: 2.mCSPC and the TITAN Study

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EP: 3.Unmet Needs and Key Takeaways When Treating mCSPC

EP: 4.Case 2 Introduction: A 62-Year-Old Man With mCSPC and Front-Line Approach

EP: 5.Using Abiraterone as a Front-Line Therapy for mCSPC and PEACE-1 Trial Details